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23D-153 (3) 142 HINCKLEY ST BP-2017-0902 GIS a: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D- 153 CITY OF NORTHAMPTON Lot -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categorv: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2017-0902 Project 4' JS-2017-001533 Est.Cost: $2612.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME DEPOT AT HOME SERVICES 082485 Lot Size(sa. ft.): 30448.44 Owner: WILSON SUZANNE T&GROCCIA LOU Zoning: URB(100)/ Applicant: HOME DEPOT AT HOME SERVICES AT.- 142 HINCKLEY ST Applicant Address: Phone: Insurance: 24 SUNRISE DR Workers Compensation PROVIDENCER102908 ISSUED ON:1/2 712017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 1 ENTRY DOOR FOR REPLACEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. _ Certificate of Occupancy Signature: FeeTvpe: Date Paid: Amount: Building 12720170:00:00 $40.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner 1._ Department use only / City�f Northampton Status of Permit +.� Building Capartment Curb Cut(Driveway Permit .212 Main Street Sewer/Septic Availability IRoom 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PloVSite Pians Other Specify APPLICATION TO'CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION !/�r l l — IVC` t.l RMReHv AddressThis section to be oompieted by office ILZ h� Map__, Lot_„ Unit Zone Overlay District_, Elm St District Ca District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record; Name{PrInU Cu Yp "T/lix1.91/ 0 -- " ,La!/AI L, LL-- __ iter 9z3 Signature 2.2 Authavized ent: Narne(P Current ailing Adtlress: _ �n� o Slynatu � Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed d5'permit app�cant _ i. Bonding ij3 {a}Building Permit Fee 2. Electrical U (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Pormit Fee 4, Mechanical(HVAC) 5.Fire Protection 6, Total-(1 +2+3+4+1) //f// Check Number 1 This Section For O(flcial Use Only Building Permit Number:_ Late eo:_,,, �Signature Bplffiirg Commissiwredin5pector of BuikNngs Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This nolua n w he filled in by Building Department Lot Si,e Frontage Setbacks Front Side L: R L R' Rear Building Height Bldg_Square Postage Open Space Footage (Ion area minus bldg&paved rklu_) t5 of Parkin S aces Fill: (volume&London) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre oris it pad of a common plan that will disturb over 1 acre? YES O NO O IF YES,then a Northampton Sic"Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑ Replacement W' doves Alteration(s) Rooting ❑ Or Doo s Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks j(=f Siding[[3] Other[a Brief Deworki 17B r'V/t r' rmx#�a - AL To Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached NarrativeRenovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete the following. a. Use of building:One Family Two Family Other b. Number of rooms m each family unit. Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar Floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank_ City Sewer Private poell City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r I, Z )9'1'/)-"s , as Owner of the subject Property hereby authorize to act on my behalf,�n all matters relative to work authorized by this building permit application a�r1 GG71T/l�r� I— zy- 17 Signature of Owner i Date I 'L as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed untle p 's and penalties rjury. Print N e Signature nerl at Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Sucervisor: Not Applicable El Name of License Holder' 7 , License Number Address r�r�-� �� � 96 Expiration Date Signature Telephone 9. Re istared Hom Im rev Hent Contra tor: Not Applicable ❑ �� -j'-3 Company Name Registration Number Addres /��� Expiration Date �� (/�� '9 Telephone �� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Atta ed Ves....... No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellines of one(1) or two(2)families and to allow such hnmcowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year d shall not be considered a hometwine Such`homemvner'shall submit to the Building Official,on a form acceptable to the Building Official that heJahe shall b responsible for all such work Performed under the buildins permit As acting Construction Supervisor your presence can 0tejob site will be required from lime to time,during and upon completion efthe work for which this permit is issued. Also be advised that with reference to Chapter 152(WorkersCompensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated,you may be liable for perwai you hire to perfomr work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances. State and Local Zoning laws and State of Massachusetts General Laws Annotated. Homeowner Signature City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: /qf7 A!,- The debris will be transported by: �/� h FZ4 The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant Job Contacts Monday,January 23,2017 Comments Lead: 9]9145] Go Advanced Search 12:35 PM InfolUpdaW Homeowner llNwmabon. Job hrformiatlon. Commissions Homeowner Mr.Louis Groccia Sale Amount $2,612.00 Balance Due: $1,741.00 Homeowner2 Product Wincore Entry Doors(8%) Costs Job Site Ack rens 142 Hinckley Street Status Sale/Material Ordered Documents FLORENCE,MA 01062 Branch Boston North Measures# 80278054 Schad Measure County HAMPSHIRE Salve Homeowner Billing Address 142 Hinckley Street Commission Rate FLORENCE, MA 01062 Consultant Name Term Data Split Como Plan Joblssues Timothy Drost 100.00°A Straight Commission Labor Update Primary Phone (413)586-9523 Work Phone Ext S-Back: No Cross ReM 1-9478938632 Siebel Ord... 124453 Order Detail Cell Phone Key Order Ent ry Work Phone 2 Sale Data 1/16/2017 FUP Data Cell Phone 2 Credit Date 1/16/2017 FPD-0ustomer Paymen Email RTP Data 1/1]/201] Postlnstall Date Permits Cross Street Start Data 2/17/2017 FPD-Home Depot 1larlf� Inspection PO Rekrrrol Store 8452-HADLEV Job NNlies0an Result Combo Base Store 8452-HADLEV Lead Paint Assumed-LSWP Requir Services Lead Source 0080 Store Associate OLS K� She.Mao TouchPoints Update Job r AM 17 10 st Work Orders IEr�kkDavidhter CythinRRLewi�T'm1 046 8 PM Mataglin 1/1712017, 10 26 AM Status ed to eoduct��D��t] 10 00 10 0Time 17 AM Timor otth Dost - j TFCyllima Ragl n 1/1]/2017 10 24 AM Ortler Entry No 1/16/2017 10 00 AM T mothy Drost motLy Drost 1/1]/201] 612 AM Credit Pentlin9 No - 1/16/201] 1000 AM Timothy Drost Timothy Drost 1/171201] 6:12 AM Sale Pentlin9 No 111612017 10 DO AM Timothy Drost Dayendbayend 1/15/20171 9:08 PM Sent to the Field No 1/16/2017 10:00AMITmothy Don Zac�Newton 1115/2017] _ 949AMConfnned-Le@Message No 1/16/2017 t000AMTunWhy Drost Internet Lead 1/11/2017, 11'.24 AM Pre-Book No 1/16/201] 10'.00 AM Timothy Drost Internet Lead 1/11/201]1 11'.24 AM Lead Entered No Clore Print n1 Nc .SRIttJv1+710J t S ,{La`f6 pfl Q 01, �µq'gdd gHJdH A. 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SCltolr�JittV"tc c9'1:9L-.Gtix�i:iv'-?V?' 113id: =- -g,3^i2�e�_�cee ;i I. li r •'i _g�o��_>;:ccrE_�;oaa_3'?ung ,! II _cD-TFJr�So�d s-`uh7199 ve ani- - __ F 12400 LrmS.N-TC'-✓ - �_ fff i p z 1 _ !i ii o�tinyloa'�z=_a-m»;,i�t_-.�r+a'.eoi_+;rn�ra is �3idL _ss--3l± ;Ciu—v' r - l_ 99i53,7Ea7i'a 91'r;°@59i•*.:e fli iv�ii9@i'.i�il?. _ 1; '� s� »o•� o.z�u - z s I r , I1 - - The Connnenweatth ofMassacliusetts Department of Industrial Accidents r I Congress Street,Suite 100 Hosoter; nfe 02 114-2017 VMV www.nmss.gov/din 1l ushers'Compensation Insurance AfTidavih Builders/Contractors/Electricinns/Plumbers. TO BE FILED WITH THE PERM TTI\'G AUTHORITY. ;kpolicant fares m6on .� REI PI Print L gild! Name (Business/Olganratlon4ndi.idua0: ¢lfY)L —'-Jf4.'1 "� Rii g `'�"'1=Vx .Address: r� ��7r/ City/State/Zip LJ 'lCe" u 6' � ?phone il: A.eyou an empmyxn check nre apprgp.inm ba,. Type or project(required): L❑lain.employ wile employees full and/or red-live) Z ❑New construction lomaruts pmpdemrorpartnershipand have no em !ogees zzmrkin'- fcrmetn-❑ p g 6. Q Remodeling znr capacity (No swrkers comp.insurance required! Z�I am a M1amemrner Joing all a-aIX nnzelf. R.u'orkcu',rn,v d,nn ncc learned 1. 9- Demolition 1mmwncr ad and will to,Ind., torsming cottneale.aw llorkocmynmperty10❑ Building addition . o'ill 1 r emat.0 convannrs cheer have.vorters'rompensadon lnsunnce or are sme ILE]Eleetrieal repairs or additions pmprlemrs wit no employees. 12.Q Plumbing repairs or additions 5XIl an a general conlmcmrand l havehiredroesubcomracmrs lisme on the mtachea shzet l h13.❑Roof repairs ese sub-colranars n have employees and have workers'comp.in fi.�We aeacgrpomtion and ifs slicers haws exercised Jair rightoRxzmoi on per MGLc 14.AC[her Dd�Sr . _ 152.s IM.and we have no employees.!No worker,comp.Insurance recinnal.l -Any applicant real checks box dl mus also fill out the section bdmr showing their zrorkars'compenztion polity inronsutiva 'Hctrad—vo who submit this affidavit indicating they are doing all work and then hire outside conlmemrs mus submit a new affidavit velirsing such. ICgddlears that check this box must atercherlan additional sheetshoeingthe name of the submntranors ani whether urnotthose rinses have employees. It the sob-enmrsetnrs have employees,they mast provide their corkers'comppolicy numbe,. t am an employer firat is providing ivorkers'compensation insurance far my employees. Betmv is tae policy and job site irrfonmtion. (r !l C-, J Insurance Company Nerhe:_ l ytl�ibl) -�; n_ )j ' ,,._ J ' 60 f J Policy.or Self ins Lie%- 1 %L_ �/�J�r+�E_('-y Expiration Date: t ` Job Site Address: City/State/Zip: Attach a copy of the workers' compensation puH6 declaration page(showing the policy number and expiration date). GO Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine note $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine crop to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. 1 do It eby ceritf a de t ri �p-gree ties of perjarr drat the information provided above is true and correct. Date: I LP - 17 Phone%: OfJ'mlaf ase only. Do rrol lydle m anis nre.,to be completed by only or town official. City or Town: Permit/License% Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Citylfown Cleric 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone d: ACC) CERTIFICATE OF LIABILITY INSURANCE 11 1ovleno s�Ym THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SE AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed, IT SUBROGATION IS WAIVED, subjett to Ne terms and conditions of Be Policy,certain policies may require an endorsement. A statement on this certificate does not corder rights to the Certificate hold.,in Had of suchendondUrn s). PRODUCER ONTA MdRSH USA.INC 'NAME' -_ PHONE FAX ^WO ALLIANC<:ENTER uc RgEdL __.. __. 1 Nc Na _ iVK I ENOX ROA=D.3W=E 2CC EMAIL — 171ANT1CA 30326 ADDRESS:_ INBVREfl1El AFFORDING COVEMGE �.HARD Ippy92InFr GAW`-10-+r _ IEWHEERA Sbodb5t msurarce Company 126387 N$UREO - INSURER B:ZWCE Andayed111n 50tarce Ce ]"0$3$ SOT EHOMEE vCES,INC -- -- -- - PBA iHE10ME-0EPOT1AT KiV1Y S SERVICEST ) MSURER" drefib Hampshire llNCp - 123891 AT-ANTA CA3D33 P0.RI(WAY.SUITE3C0 IxSURERD_Illlmis NaLbnal lnsumlwe Lempeny 23011 A6VITA.GA 3D339 INSURER E' INSURER F: COVERAGES CERTIFICATE NUMBER: ATL003]g669519 REVISION NUMBER:8 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXC'.USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Imay rypE OFIHSURA NCE AOCC348R POLICY EFF POLICY EXP ---- DMS LIF PO VLY NVMBER MMID MM/p A X COMMERCIAL GENERAL LIABILITY GLQEQ81119-CB 0ONVO016 '03ro1121111 FAOHOOCURRENCE IS 5.000,OW DAMAGE LOREN CP iIMS.'M1OE X CLCUR DED ELGES Ee—Per EXCLUDED LIMITS OF POLICY XS MEDEXP n EXCLUCED '-0F SIR:SIM PER OCC ' PERSONAL SARV Irv.IDRr s 9000,510 F I _S SER GENERAL AGGREGATE S 9,om,ow A SOL EC- L^C PRODUCTS-COMPIOPAGG .S 9.I00t OTHER IS 9 AUTOMI LIABILITY BAP 29388CH3 010112016 0310120t] LO aB�In BSLINGLE LIMIT ' S l�6fm Xx11-1 BODILYINJURV Per Ferson) I,5 _ Ax dLPMJEO SCHEDULED SELF INSURED AUTO P4Y Dx1G BODILY INJURY(Per axldem,'4 ICNa Y - W EO Ftt RO- RDAMAGE W J. L ITS 1110_AUTC$ ' Edr— r) __ S_.. UMBRELLA LAS OCCUR EACH OCCURRENCE _ S _ EXCESS LIAR CLAMS-MAOE AGGREGATES OFF RETENTION S WORKERS COMPENSATION W(A155192151A0$) 10310112016 103i011'N11 X PER -AND EMPLOYERS LABILITY :STATUTE I —ERE PFORPCTOANIRiNEEEXE.OT''V= YI sIINI,NA M1'C0155192111AK.KYNN NJ VT) 016L261fi DL011209 loop MOB) OF9CERIMEMBER EYCLUDEO J IELFALH ACCIDENT _^S IO Ramu.lory no NH WG01$$19216(FL) 63ID1p016 03x11 YN1) I'. EL DISEASE EA EMPLOYED5 t,f;CO L'� I, 0es:nbeunoev OECRIPTION OF OPERATIONS Helm, 3W11rund on Additional Pro, ' EL DISEASEPOLICYLIMIT r IDoc SW DESAMPOON OF OPERATIONS I LOCATIONS I VEHICLES ACORD 101,AJ4IEonal Remnlls Schad ,maybe rammed R mom sone Is requirme EVIDENCE OFINSURANCE CERTIFICATE HOLDER CANCELLATION TSCA HOME 3ERIJOES INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CBA TIE SOME TRACT AT HOME AERVOE5 THE EXMRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2955 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. n r->NTA.GA X339 AUTHORQED REORESEFTATNE of Ma..USA Inc. Manashl Mukhegas Stn.nnoy �4-+.rc+u�<s. ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Office of Consumer affairs and Business Regulation 10 Park Plaza - Suite 51701 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC, Expiration: 813(2018 RICHARD TROIA 2455 PACES FERRY ROAD, HSC C-11 ATLANTA, GA 30339 Update Address and return card.Mark reason For change. Address Renewal - t Employment j Lost'Card Office of Consumer Affairs R Ilusinzss Regulaeion License or registration valid for individual use anly HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration: 126893 Type: 10 Park Plain-Suite 5174 Expiration: 8l312ols Supplement Gard Bouton, MA 02116 THD AT HOME SERVICES, INC. THE HOME DEPOT AT HOME SERVICES 1 RICHARD TROIA 2455 PACES FERRY ROAD, HSC � .�.L ' �� T y L ATiANTA, GA 30339 t t ,<y,G Dudrrscvrerary hot valid without sr¢uature